"We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’" This stark statement encapsulates the growing dilemma facing the healthcare industry as its physician workforce ages: how to ensure patient safety without alienating or unfairly discriminating against experienced doctors nearing the end of their careers. The challenge lies in balancing the invaluable knowledge and skills of veteran practitioners with the potential for cognitive and physical declines that can impact their ability to perform complex medical procedures.
The increasing age of the physician population presents a complex challenge for healthcare systems nationwide. As more doctors remain in practice well into their 70s and beyond, concerns are mounting regarding their cognitive and physical capabilities. While many seasoned physicians maintain their sharp intellect and diagnostic prowess, a segment of this aging cohort may experience declines that could potentially affect patient care. This reality necessitates a delicate approach to implementing evaluation and screening programs that are both effective in safeguarding patients and fair to the physicians themselves, especially in light of physician shortages that make losing experienced practitioners particularly detrimental.
The Silent Struggle in the Operating Room
The issue gained stark visibility through the experience of a 78-year-old surgical oncologist practicing in a Southern city. Colleagues began to observe subtle but concerning changes in his demeanor and performance during surgical procedures. Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore, described how the surgeon seemed "hesitant, not sure of how to go on to the next step without being prompted" by his surgical assistants. This hesitation, a departure from the decisive actions expected in a high-stakes surgical environment, raised red flags.
The chief of surgery, recognizing the potential implications for patient safety, took a decisive step. Citing concerns about the doctor’s cognitive function, he stipulated that the surgeon’s credentials to practice surgery would not be renewed unless he underwent a comprehensive evaluation. This decision, while potentially difficult for the physician, underscored a growing institutional responsibility to proactively address age-related cognitive changes in practicing physicians.
The Sinai Model: A Comprehensive Two-Day Assessment
Sinai Hospital, recognizing the burgeoning demographic shift in its medical staff, inaugurated its Aging Surgeon Program in 2015. This program mandates a thorough two-day physical and cognitive assessment for surgeons aged 75 and older. Since its inception, approximately 30 surgeons from across the country have participated. The 78-year-old oncologist in question was not a volunteer; his participation was a requirement for continued surgical privileges.
The comprehensive assessment, involving a battery of tests administered by neuropsychologists and other specialists, aims to identify any potential impairments that could affect a physician’s ability to practice safely. In this particular case, the tests revealed mild cognitive impairment. While not necessarily indicative of imminent dementia, this diagnosis carries significant implications for a surgeon whose practice involves intricate and complex procedures.
The neuropsychologist’s report was clear: the surgeon’s identified difficulties were "likely to impact his ability to practice medicine as he is doing presently, e.g. conducting complex surgical procedures." This finding presented a critical juncture. It did not automatically necessitate retirement, but it did require a re-evaluation of his role within the hospital. As Katlic noted, the surgeon "retained a lifetime of knowledge that had not been impacted by cognitive changes." The hospital’s solution was to transition him out of the operating room, allowing him to continue seeing patients in a clinical setting. This approach highlights a key tenet of effective late-career programs: to preserve valuable physician experience while mitigating risks associated with specific high-demand roles.
A Growing National Trend: The Aging Physician Workforce
The situation of this Southern oncologist is far from isolated. The American physician workforce is aging rapidly. In 2005, over 11% of practicing physicians were 65 or older, according to the American Medical Association. By last year, that proportion had surged to 22.4%, representing nearly 203,000 older practitioners. This demographic shift is occurring against a backdrop of significant physician shortages, particularly in rural areas and critical specialties like primary care. The imperative, therefore, is to retain the expertise of these veteran doctors without compromising patient safety.
Research supports the need for such considerations. Thomas Gallagher, an internist and bioethicist at the University of Washington who has studied late-career physician trajectories, points to documented "gradual decline in physicians’ cognitive abilities starting in their mid-60s." This decline can manifest as slower reaction times and the potential for knowledge to become outdated. However, Gallagher also emphasizes the significant variability in cognitive function among older physicians. "Some practitioners continue to do as well as they did in their 40s and 50s, and others really start to struggle," he observed. This variability underscores the inadequacy of blanket policies and the need for individualized assessments.
The Rise and Stumble of Late-Career Practitioner Programs
In response to these emerging concerns, several health organizations have initiated "late-career practitioner programs." These programs often mandate cognitive and physical screenings for older doctors. UVA Health at the University of Virginia, for instance, launched its program in 2011 and has since screened approximately 200 older practitioners. In their experience, only four cases resulted in significant changes to a doctor’s practice or privileges. Stanford Health Care and Penn Medicine at the University of Pennsylvania also established similar programs around the same time.
Estimates suggest that as many as 200 such programs may exist across the country, though no definitive tracking mechanism is in place. However, given the more than 6,000 hospitals in the United States, Gallagher characterizes these programs as constituting "a vast minority." The progress in establishing these programs may have even reversed in recent years.
Legal Challenges and Lingering Reluctance
A significant impediment to the widespread adoption and continuation of these programs has been a federal lawsuit and the medical profession’s inherent reluctance to implement mandatory evaluations for its senior members. Late-career programs typically require physicians aged 70 and older to undergo evaluations prior to the renewal of their privileges and credentials. Those with initial concerning results often undergo confirmatory testing. Subsequently, regular rescreening, usually annually or biennially, is common.
These mandates have understandably been unpopular among the target demographic. Rocco Orlando, senior strategic adviser to Hartford HealthCare, which operates eight Connecticut hospitals and initiated its late-career program in 2018, noted the common refrain from doctors: "’I’ll know when it’s time to stand down.’ It turns out not to be true."
Data from early adopters of these programs have provided compelling evidence for their necessity. Hartford HealthCare’s initial findings from its program revealed that 14.4% of 160 screened practitioners aged 70 and older showed some degree of cognitive impairment. Similarly, a study at Yale New Haven Hospital, which implemented mandatory cognitive screening for medical staff starting at age 70, found that 12.7% of the first 141 clinicians tested "demonstrated cognitive deficits that were likely to impair their ability to practice medicine independently."
Proponents argue that such screening programs are crucial for preventing patient harm and for guiding impaired physicians toward less demanding roles or, when necessary, retirement. Orlando expressed his initial hope that such programs would be adopted nationwide, noting the relatively low annual cost of Hartford’s program, estimated at $50,000 to $60,000. However, he has observed "zero progress" in recent years, stating, "Probably we’ve gone backward."
The primary catalyst for this regression was a 2020 lawsuit filed by the federal Equal Employment Opportunity Commission (EEOC) against Yale New Haven Hospital, alleging age and disability discrimination based on its testing efforts. While the EEOC declined to comment on the lawsuit’s status, the legal action has cast a long shadow. The lawsuit prompted several other organizations, including Hartford HealthCare and Driscoll Children’s Hospital in Texas, to pause or discontinue their programs. Few new initiatives have emerged in its wake. As Gallagher observed, the lawsuit "made lots of organizations uncomfortable about sticking their necks out."
Implementing late-career programs has always been an uphill battle. "Doctors don’t like to be regulated," acknowledged Katlic. These programs have "in some cases been very controversial, and they’ve been blocked by influential physicians," he added. The current landscape sees most national medical organizations recommending only voluntary screening and peer reporting, a strategy that many experts deem insufficient.
The Limitations of Voluntary Measures
Both voluntary screening and peer reporting have proven to be largely ineffective. Gallagher explained that physicians are often "hesitant to share their concerns about their colleagues," a reluctance rooted in complex "power dynamics" within the profession. Furthermore, the very nature of cognitive decline can impair self-awareness. "They’re the last to know that they’re not themselves," he stated, referring to the reduced insight that can accompany such impairments.
Charting a Fairer Path Forward
In a recent commentary in The New England Journal of Medicine, Gallagher and his co-authors proposed procedural policies designed to promote fairness in late-career screening. Their recommendations, based on an analysis of existing programs and interviews with their leaders, aim to create a system that physicians are more likely to embrace. "How can we design these programs in a way that’s fair and that therefore physicians are more apt to participate in?" he posited. Key elements include ensuring confidentiality and establishing robust safeguards, such as an appeals process.
Gallagher emphasized that numerous "accommodations" can be made for doctors whose assessments indicate a need for modified roles. These could include less demanding schedules, focusing on routine procedures while delegating complex surgeries, or transitioning to roles in teaching, mentoring, and consulting. However, he also noted that a substantial number of older doctors opt for retirement rather than face mandatory evaluations.
Looking ahead, a potential solution could involve regularly screening every practitioner, regardless of age. While this approach might be inefficient and costly with current testing methodologies, it would effectively circumvent allegations of age discrimination. The development of faster, more reliable cognitive tests, reportedly in the research pipeline, could make this a more viable option.
In the interim, changing the culture within healthcare organizations is paramount. Orlando advocates for fostering an environment that encourages peer reporting and commends those who demonstrate the "courage to speak up." He concludes with a powerful call to action: "If you see something, say something." This principle, he stresses, applies to all healthcare professionals witnessing any physician, at any age, faltering. "We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’" This shift in perspective is crucial to navigating the complex ethical and practical challenges of ensuring both the well-being of patients and the dignity of aging physicians.